Abstract
In current American medical practice, autonomy is assumed to be more valuable than human life: if a patient autonomously refuses lifesaving treatment, the doctors are supposed to let him die. In this paper we discuss two values that might be at stake in such clinical contexts. Usually, we hear only of autonomy and best interests. However, here, autonomy is ambiguous between two concepts—concepts that are tied to different values and to different philosophical traditions. In some cases, the two values (that of agency and that of authenticity) entail different outcomes. We argue that the comparative value of these values needs to be assessed.
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Notes
A word should be said about Kant. There is an unfortunate tendency for bioethicists to appeal only to the Kant of the Groundwork of the Metaphysics of Morals. However, this is merely one book among several that are fundamental for Kant’s moral thought. Limiting oneself to the Groundwork distorts one’s understanding of that moral thought—and even of the Groundwork, itself. In the Groundwork, Kant claims that the good will is the only thing whose goodness is unconditional (ohne Einschränkung). This claim is often, correctly, tied to his use, in the Groundwork, of the term “autonomy”: autonomy, in Kant’s use, obtains only when one acts with a good will, i.e., from respect for the moral law. In his subsequent works, however, Kant came to see that autonomy and freedom are different. The latter can obtain even when the former is absent; otherwise, there could be no responsibility for one’s immoral actions. In his books The Metaphysics of Morals and Religion within the Boundaries of Mere Reason, Kant stresses that what is distinctively human is the capacity to make choices, even immoral choices (indeed, it is the capacity to make choices that may not be treated as a mere means). In understanding Kant’s contribution to the foundations of bioethics, it is vital not to restrict oneself to the Groundwork.
Drawing on a different philosophical tradition, that of Aristotle and Aquinas, Philippa Foot has emphasized this point. See Foot [4, pp. 52–65].
Like “autonomy,” the term “authenticity” has been used in many ways. Unfortunately, it is not possible here to detail the distinctions between our usage and the myriad others.
It is also worth emphasizing that considerations of authenticity do not always point toward accepting treatment. Ms. W, described on the next page, is one such example. But even with Ms. G, her situation might have seemed to her so dire that the prospect of making for herself a new kind of life and, in effect, a new kind of self might have appeared not worth the trouble. Here, considerations of authenticity might have pointed toward refusing treatment. We thank an anonymous reviewer for pressing us to address this issue.
Our sketch of the agency/authenticity distinction lacks adequate philosophical development. What is needed is a richer account of what the two values amount to. As a first step, one might compare the work of an agency advocate, Stephen Darwall (see especially [8, 9]), with that of Joseph Raz, who might be cast as something like an authenticity advocate (see especially [10]). One might also look at many of the essays of Harry Frankfurt in the collections The Importance of What We Care About [11] and Necessity, Volition, and Love [12]. Finally, in a quite complex way, Christine Korsgaard’s discussion of agency and integrity is of relevance; see [13].
It should also be kept in mind that one cannot vindicate the value of agency by appealing to the epistemic advantages of a rule that lets patients decide. The value of agency is precisely not tied to patient knowledge (beyond the minimum needed for legal competency). The thought that the patient knows best would put the stress not on the value of the exercise of the will (agency) but on the value of a good outcome (however that is construed).
For a rejection of the ideal of authenticity, see Strawson [14].
Gerald Dworkin defines weak paternalism as follows: “A weak paternalist believes that it is legitimate to interfere with the means that agents choose to achieve their ends, if those means are likely to defeat those ends. So if a person really prefers safety to convenience then it is legitimate to force them to wear seatbelts…. Another way of putting this: we may interfere with mistakes about the facts but not mistakes about values. So if a person tries to jump out of a window believing he will float gently to the ground we may restrain him. If he jumps because he believes that it is important to be spontaneous we may not” [15].
In defending the value of agency in medical contexts, people often invoke the “right to bodily integrity.” If someone keeps me from choosing what to do with my body, my agency is violated in an especially important way. On scrutiny, though, the issue turns out to be complicated. One way the bodily integrity claim is often spelled out is via the claim that it would be morally wrong to prevent me from taking a physical risk—to interfere with my body—as long as I am mentally competent and the proposed action does not harm or imperil any third-party. Yet this is not clearly right. If my child is in a burning building, I will want to rush in to try to save her. I would certainly be emotionally distraught, but I would not be incompetent or irrational. Nevertheless, the police are likely physically to prevent me from entering the building. Their reason will be that the risk to me is too great. (If preferred, the stage can be set more fully by assuming that the fire marshal has already ordered the fire fighters out of the building.) Libertarians might disagree with a law that requires the police to restrain me for my own good. However, most people would probably accept this as a proper constraint on my risk-taking. At any rate, the case is not obviously one in which the police would be morally wrong to restrain me. Bodily integrity is not obviously more valuable than life itself.
One might think that both agency and authenticity are important values, and that in actual cases, they should be balanced against one another (maybe even sometimes along with best interests considerations). In the clinical setting one might favor value pluralism over value monism. This has some common sense appeal. Still, value pluralism requires that, in many cases, someone balance the values and decide what decision, on balance, is required. Authority must thus be put in the hands of a doctor or some other health care professional. Logically, pluralism involves denying that the patient’s mere agency has overriding authority.
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Brudney, D., Lantos, J. Agency and authenticity: Which value grounds patient choice?. Theor Med Bioeth 32, 217–227 (2011). https://doi.org/10.1007/s11017-011-9180-2
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DOI: https://doi.org/10.1007/s11017-011-9180-2